Investigation Report Into The Death Of A Prisoner

Published on May 06 2014

The Prisoner Ombudsman for Northern Ireland today published an investigation report into the death of a prisoner, “Mr F,” who died by hanging at Maghaberry Prison.

Mr F was already a troubled man when he arrived in prison, and he had previously attempted suicide in the community.  However he successfully concealed his distress from prison officers and healthcare staff, and nobody in the prison realised he was so disturbed that he would take his own life. 

A range of supports were put in place for Mr F, and several features of good practice by NIPS and SEHSCT personnel are commended.

Nonetheless nineteen recommendations are made to improve standards of prisoner care and help prevent serious incidents or deaths in the future. Four previous Prisoner Ombudsman recommendations which were accepted by the NIPS - involving the SPAR process and first aid training - were not fully implemented in this case. 

The Northern Ireland Prison Service and the South Eastern Health and Social Care Trust have confirmed that due care and attention will be given to the recommendations that apply to them.

Prisoner Ombudsman Tom McGonigle said “There were significant levels of intervention with Mr F during his time in Maghaberry. Several staff from a variety of disciplines demonstrated genuine care for his wellbeing, and while he saw a range of mental health specialists, his decision to hang himself could not have been predicted.” 

Media contact:
McCann Public Relations, Telephone: 02890 666322
Maria McCann: 07802934246 or Natalie Mackin: 07974935855

Notes to editors:

1. The Prisoner Ombudsman’s Terms of Reference require the Office to investigate all deaths in prison custody since September 2005. Please see for further information.

2.  In line with the Prisoner Ombudsman’s Terms of Reference a copy of this report has also been sent to the Coroners Service for Northern Ireland.

3. Publication of Reports
The Prisoner Ombudsman strives to ensure that readers can establish the facts of the case, and that all necessary information is shared in the public interest.  This is balanced against our legal obligations in respect of data protection and privacy, and we therefore take careful account of next of kin views when considering publication.  If publishing, we offer to anonymise reports and redact dates or other identifying information, in order to preserve the privacy of a deceased prisoner and their family.